Provider Demographics
NPI:1023065844
Name:POUDRE VALLEY OPEN MRI, LLC
Entity type:Organization
Organization Name:POUDRE VALLEY OPEN MRI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:BELICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-884-3096
Mailing Address - Street 1:PO BOX 6102
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-6102
Mailing Address - Country:US
Mailing Address - Phone:415-884-3418
Mailing Address - Fax:
Practice Address - Street 1:2420 E PROSPECT RD
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-9729
Practice Address - Country:US
Practice Address - Phone:970-493-0567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO261QR0200X, 261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00080903OtherRAILROAD MEDICARE
CO81833237Medicaid
CO81833237Medicaid